Performance Improvement: Coding Scenarios- Series 3

HIV/AIDS Care: Coding Scenarios Series 3

Prepared By: Stacey L. Murphy, MPA, RHIA, CPC AHIMA Approved ICD-10-CM/ICD-10-CM Trainer

Learning Outcomes • Review the CPT and ICD-9-CM codes learned in series 1 and series 2 • Review the importance of proper code sequencing • Review coding scenarios which reflect accurate reporting of the codes for HIV/AIDS medical care

2

Acronyms Used • • • •

• • • • • •

CPT – Current Procedural Terminology Dx – Diagnosis E&M – Evaluation and Management HCPCS – Healthcare Common Procedure Coding System HIV 1 - Human Immunodeficiency Virus 1 HIV 2 - Human Immunodeficiency Virus 2 ICD-9-CM – International Classification of Diseases, 9th Revision, Clinical Modification OI – Opportunistic Infection PDx – Principal Diagnosis SDx – Secondary Diagnosis

3

E & M Service Codes (con’t) New Patient Visit

Established Patient

(Preventive medicine)

(Preventive medicine)

• 99381 – younger than one

• 99391 – younger than one

• 99382 – 1 yrs to 4 yrs

• 99392 – 1 yrs to 4 yrs

• 99383 – 5 yrs to 11 yrs

• 99393 – 5 yrs to 11 yrs

• 99384 – 12 yrs to 17 yrs

• 99394 – 12 yrs to 17 yrs

• 99385 – 18 yrs to 39 yrs

• 99395 – 18 yrs to 39 yrs

• 99386 – 40 yrs to 64 yrs

• 99396 – 40 yrs to 64 yrs

• 99387 – 65 years and older

• 99397 – 65 years and older 4

E & M Service Codes (con’t) Preventive Medicine Counseling and/or Risk Factor Intervention Visits (without history and physical exam) • 99401 – 15 minutes • 99402 – 30 minutes • 99403 – 45 minutes • 99404 – 60 minutes Note: These codes are included in the preventive medicine visit codes. Do not report with CPT codes 99381-99397

5

E & M Service Codes (con’t) New Patient Office (Clinic) Visit

Established Patient Office (Clinic) Visit

• 99201 – 10 minutes

• 99211 – 5 minutes

• 99202 – 20 minutes

• 99212 – 10 minutes

• 99203 – 30 minutes

• 99213 – 15 minutes

• 99204 – 45 minutes

• 99214 – 25 minutes

• 99205 – 60 minutes

• 99215 – 40 minutes

6

HIV Test Codes HIV Antibody • • • • • •

86701 – HIV 1; single result G0435 – HIV 1 and/or HIV 2; single result 86702 – HIV 2, single result 86703 – HIV 1 & HIV 2; single result 86689 – HIV confirmatory (Western Blot) Rapid HIV tests – G0435, 86701, 86702 and 86703 ─ Orasure Technology ─ Trinity Biotech Uni-Gold ─ One test payable every 6 months

Venipuncture – blood sample or urine sample by catheterization • 36415 – routine venipuncture • If HIV blood screening performed, must also report code 36415

7

HIV Test Codes (con’t) HIV Antigen • 87389 - EIA HIV 1 antibody with HIV 1 & HIV2 antigens; qualitative or semi-quantitative; single step • G0432 - EIA; HIV 1 and/or HIV 2 • 87390 - EIA HIV 1; qualitative or semi-quantitative; multi-step • 87391 - EIA HIV 2; qualitative or semi-quantitative; multi-step • G0433 - ELISA; HIV 1 and/or HIV 2 • 87534 - DNA/RNA; HIV 1; direct probe • 87535 - DNA/RNA; HIV 1; amplified probe • 87536 - DNA/RNA; HIV 1; quantification • 87537 - DNA/RNA; HIV 2; direct probe • 87538 - DNA/RNA; HIV 2; amplified probe • 87539 - DNA/RNA; HIV 2 quantification 8

What are Modifiers?

Modifiers are two digit (numeric or alphanumeric) codes that indicate that a procedure or service has been altered by a specific circumstance, but has not changed the code’s definition • There are CPT modifiers and HCPCS modifiers • Some modifiers impact reimbursement • Modifiers are never reported on ICD-9-CM codes – ICD-9-CM codes covered in Series 2

• Each state Medicaid agency determines the approved modifiers • Contact your local Medicaid agency for specific guidance 9

Modifiers (con’t) Modifier 25 - Significant, Separately, Identifiable E&M Service by Same MD on the Same Day of a Procedure, Service or Other E&M Service • • • •

Only report with E&M service codes (99201-99499) Do NOT report with any other CPT code type Do NOT report with HCPCS codes Contact your local Medicaid agency for specific guidance

10

Modifiers (con’t) Modifier 92 - Alternative Laboratory Platform Testing With current CDC recommendations on routine testing and the move toward HIV testing as a routine part of care, more providers may use rapid test kits.

Several of these are CLIA-waived and suitable for use in physician offices. The following is the CPT guidance for use of this modifier: “When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing 86701-86703).”

• Only report with Path/Lab test codes (86701-86703, G0433G0435) • Do NOT report on any other code type • Do NOT report with HCPCS codes • Contact your local Medicaid agency for specific guidance

11

Modifiers (con’t) Modifier QW - CLIA waived test In accordance with the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), a laboratory provider must have: a Certificate of Compliance, a Certificate of Accreditation or a Certificate of Registration in order to perform clinical diagnostic laboratory procedures of high or moderate complexity.

Waived tests include test systems cleared by the FDA designated as simple, have a low risk for error and are approved for waiver under the CLIA criteria.

• Only report with Path/Lab test codes (86701-86703, G0433G0435) • Do NOT report on any other code type • If a combination of waived and non-waived tests are performed, modifier QW should not be used.

• Contact your local Medicaid agency for specific guidance 12

ICD-9-CM Codes • V01.79 – Exposure to HIV/AIDS – Pre-exposure prophylaxis

• V67.9 – Follow Up Exam • V69.2 High Risk Sexual Behavior • V69.8 – Other Problems Related to Lifestyle – Asymptomatic High Risk – Report as secondary Dx code only (when applicable)

• V70.0 – Routine General Medical Exam (Well Visit) • V73.89 – Special Screening for Other Specified Viral Diseases (HIV/AIDS)

• V08 – Asymptomatic HIV – HIV+ – HIV + status

• V65.44 - HIV Counseling • 042 – HIV Disease – – – – –

AIDS AIDS Like Syndrome AIDS Related Complex (ARC) Symptomatic HIV Infection HIV 1

• 079.53 – HIV 2 – Report as secondary Dx code only (when applicable)

• 795.71 – Nonspecific Evidence of HIV – Inconclusive HIV Test

13

CASE STUDIES

14

HIV Counseling without Testing Case study#1: A 17 year old patient presents to her GYN to discuss contraception options and safe sex. Dr. Attending counsels the patient on the various methods and suggests and HIV test. The patient agrees, but then minutes later declined to the HIV screening test. Dr. Attending spends 45 minutes counseling the patient and asked her to reconsider the HIV test at a later date.

Report a preventive medicine counseling CPT code based on the total time spent with the patient

Office Service 99403

Report the HIV Counseling

Dx Code

ICD-9-CM code

V65.44

15

HIV Counseling without Testing Case Study#1 Rationale • •

• •

•

The patient presents for counseling on the various contraception options and safe sex.

There is no distinction between new patient vs. established patient. Select the code based on the amount of time spent counseling the patient – CPT code 99403 (refer to slides 4-6) Do NOT report the preventive medicine visit E&M codes because in this instance, the patient presented for counseling only All claims require a diagnosis code that supports the reason for the patient encounter and to support procedures and services performed during the encounter.

The patient presents for counseling on the various contraception options and safe sex (HIV counseling) – ICD-9-CM code V65.44 (refer to slide 13)

16

HIV Pre-Testing with Preventive Care Case study#2: A 27 year old patient presents to his primary care physician’s office concerned about recently having unprotected sex and requests an HIV test. Since this is a new patient, Dr. Attending decides to perform a preventive medicine visit exam and spends 35 minutes counseling the patient and performs a rapid HIV test.

Report a preventive medicine CPT code based on the patient’s age and new patient status with the applicable modifier

Office Service 99385-25

Report Dx Codes: Well visit HIV screening HIV counseling High risk behavior

Report the rapid HIV test CPT code with the applicable modifier

Test Product 86701-92 or QW

Report Dx Codes: HIV screening HIV counseling High risk behavior

V70.0 V73.89 V65.44 V69.2 V73.89 V65.44 V69.2 17

HIV Pre-Testing with Preventive Care Case Study#2 Rationale This is a general medical exam (well visit) for a patient that presents with no medical problems and HIV testing is performed • Report the initial preventive medicine visit E&M code – CPT 99385 (refer to slides 4-6) • Since the preventive medicine visit E&M codes include counseling as a component, do NOT report the counseling codes separately.

• The medical record does not denote that this is an HIV 2 test, so in this instance report the rapid HIV 1 test code – CPT 86701 (refer to slides 7-8) • Both codes require the use of modifiers (refer to slides 9-12) • Append modifier 25 to the preventive medicine E&M code to designate a separate, identifiable service • Append modifier 92 or QC to the HIV test code (check with your local Medicaid agency for the applicable modifier) •

18

HIV Pre-Testing with Preventive Care Case Study#2 Rationale (con’t) – refer to slide 13 The diagnoses codes should be sequenced as follows: • • • •

The physician performs a well adult exam – ICD-9-CM code V70.0 The physician performs an HIV (special) screening test – ICD-9-CM code V73.89 The physician counsels the patient (HIV counseling) – ICD-9-CM code V65.44 The patient indicates that they recently had unprotected sex – ICD9-CM code V69.2

19

HIV Pre-Testing with Preventive Care Case study#3: A 27 year old patient presents to his primary care physician’s office concerned about recently having unprotected sex and requests an HIV test. The physician notices that the patient is also due for a well visit this year and performs it. Dr. Attending decides to perform a preventive medicine visit exam and spends 35 minutes counseling the patient and performs a rapid HIV test. This is an established patient.

Report a preventive medicine code based on the patient’s age and established patient status with the applicable modifier Report the rapid HIV test code with the applicable modifier

Office Service 99395-25

Report Dx Codes: Well visit HIV screening HIV counseling High risk behavior

V70.0 V73.89 V65.44 V69.2

Test Product 86701-92 or QW

Report Dx Codes: HIV screening HIV counseling High risk behavior

V73.89 V65.44 V69.2 20

HIV Pre-Testing with Preventive Care Case Study#3 Rationale • This is a general medical exam (well visit) for a patient that presents with no medical problems and HIV testing is performed • Report the established preventive medicine visit E&M code – CPT 99395 (refer to slides 4-6) • Since the preventive medicine visit E&M codes include counseling as a component, do NOT report the counseling codes separately.

• The medical record does not denote that this is an HIV 2 test, so in this instance report the rapid HIV 1 test code – CPT 86701(refer to slides 7-8) • Both codes require the use of modifiers (refer to slides 9-12) • Append modifier 25 to the preventive medicine E&M code to designate a separate, identifiable service • Append modifier 92 or QC to the HIV test code (check with your local Medicaid agency for the applicable modifier) 21

HIV Pre-Testing with Preventive Care Case Study#3 Rationale (con’t) – refer to slide 13 • This is a general medical exam (well visit) for a patient that presents with no medical problems • The codes should be sequenced as follows: ─ The physician performs a well adult exam – ICD-9-CM code V70.0 ─ The physician performs an HIV (special) screening test – ICD-9-CM code V73.89 ─ The physician counsels the patient (HIV counseling) – ICD-9-CM code V65.44 ─ The patient indicates that they recently had unprotected sex – ICD9-CM code V69.2

22

HIV Post Test Counseling Negative Results

Case study#4: The patient returns for their HIV test results.

The physician advises the patient that the results are negative and counsels the patient for 30 minutes on the importance of safe sex and contraceptive methods. The physician also distributes contraception and advises the patient to return in 3 months for a retest.

Report a preventive medicine counseling CPT code based on the total time spent counseling the patient

CPT Code 99402

Report Dx Codes: HIV Counseling High Risk Behavior

V65.44 V69.2

23

HIV Post Test Counseling Negative Results

Case Study#4 Rationale •

• •

The patient returned for their HIV test results. Since the results are negative and counseling on safe sex was documented, report the preventive medicine counseling E&M code based Select the code based on the amount of time spent counseling the patient – CPT code 99402 99395 (refer to slides 4-6) The patient returned for their HIV test results. The physician documents the results and counsels the patient on the importance of safe sex practices – ICD-9CM codes V65.44 and V69.2 (refer to slide 13)

24

HIV Post Test Counseling Positive Results (Asymptomatic)

Case study#5: The patient returns for their HIV test results. The physician advises the patient that they are HIV+ (asymptomatic HIV). The physician counsels the patient and explains what it means to have a diagnosis of HIV+ vs HIV infection, the proper use of medications, implements a treatment plan and advises the patient to return in 3 months for a retest. This is an established patient visit Report an established patient office visit E&M CPT code based on level of history, exam and medical decision making

Office E&M 99213

Report Dx Codes: Asymptomatic HIV (HIV+, HIV+ status) HIV Counseling

V08

V65.44

25

HIV Post Test Counseling Positive Results (Asymptomatic)

Case Study#5 Rationale • The patient returned for their HIV test results. Since the results are positive, this is considered a sick visit encounter • A brief history and exam is performed and documented in the health record.

• Prescriptions are dispensed and documented in the health record • Instructions for proper medication use and treatment plan are both documented in the health record • The E&M components are: expanded problem focused history, expanded problem focused exam and medical decision making is low • Assign an established patient E&M code based on the level of care provided.

• The E&M code for this scenario is 99213 (refer to slides 4-6) 26

HIV Post Test Counseling Positive Results (Asymptomatic)

Case Study#5 Rationale (con’t) – refer to slide 13 • •

The patient returned for their HIV test results. The medical record states that the patient is asymptomatic HIV (HIV+) – ICD-9-CM code V08 The physician counsels the patient. The physician gives the patient some literature that explains what asymptomatic HIV is, the difference between asymptomatic HIV and symptomatic HIV and also discusses the importance of safe sex practices – ICD-9-CM codes V65.44

27

HIV Post Test Counseling Positive Results (Symptomatic)

Case study#6: The patient returns for their HIV test results.

The physician advises the patient that they have the HIV infection (symptomatic HIV/AIDS). The physician counsels the patient and explains in detail what HIV infection is. The physician implements a treatment plan, discusses the importance of taking medications and the importance of practicing safe sex at all times. This is an established patient visit Report an established patient office visit E&M CPT code based on level of history, exam and medical decision making

Office E&M 99213

Report Dx Codes: AIDS (HIV infection) HIV Counseling

042

V65.44

28

HIV Post Test Counseling Positive Results (Symptomatic)

Case Study#6 Rationale • The patient returned for their HIV test results. Since the results are positive, this is considered a sick visit encounter • A brief history and exam is performed and documented in the health record.

• Prescriptions are dispensed and documented in the health record • Instructions for proper medication use and treatment plan are both documented in the health record • The E&M components are: expanded problem focused history, expanded problem focused exam and medical decision making is low • Assign an established patient E&M code based on the level of care provided.

• The E&M code for this scenario is 99213 (refer to slides 4-6) 29

HIV Post Test Counseling Positive Results (Symptomatic)

Case Study#6 Rationale (con’t) – refer to slide 13 • The patient returned for their HIV test results. The medical record states that the patient has AIDS (symptomatic HIV) – ICD-9-CM code 042 • The physician counsels the patient and explains in detail what HIV infection is. The physician implements a treatment plan, discusses the importance of taking medications and the importance of practicing safe sex at all times. – ICD-9-CM codes V65.44

30

HIV Post Test Counseling Positive Results (Symptomatic)

Case study#7: The patient returns for their HIV test results.

The physician advises the patient that they have HIV-1 and HIV-2. The physician counsels the patient and explains in detail what HIV infection is. The physician implements a treatment plan, discusses the importance of taking medications and the importance of practicing safe sex at all times. This is an established patient visit Report an established patient office visit E&M CPT code based on level of history, exam and medical decision making

Office E&M 99213

Report Dx Codes: AIDS (HIV infection) HIV-2 Infection HIV Counseling

042 079.53 V65.44 31

HIV Post Test Counseling Positive Results (Symptomatic)

Case Study#7 Rationale • The patient returned for their HIV test results. Since the results are positive, this is considered a sick visit encounter • A brief history and exam is performed and documented in the health record.

• Prescriptions are dispensed and documented in the health record • Instructions for proper medication use and treatment plan are both documented in the health record • The E&M components are: expanded problem focused history, expanded problem focused exam and medical decision making is low • Assign an established patient E&M code based on the level of care provided.

• The E&M code for this scenario is 99213 (refer to slides 4-6) 32

HIV Post Test Counseling Positive Results (Symptomatic)

Case Study#7 Rationale (con’t) – refer to slide 13 • The patient returned for their HIV test results. The medical record states that the patient has HIV-1 and HIV-2 – ICD-9-CM codes 042 + 079.53 • Assign ICD-9-CM code 042 for HIV–1. This code is always sequenced as the principal diagnosis code (PDx) • Assign ICD-9-CM code 079.53 for HIV-2. This code is always sequenced as the secondary diagnosis code (SDx). This code is never reported alone • The physician counsels the patient and explains in detail what HIV infection is. The physician implements a treatment plan, discusses the importance of taking medications and the importance of practicing safe sex at all times. – ICD-9-CM codes V65.44 33

Antiretroviral Therapy Visit Newborn

Case study#8: An HIV+ mom presents to the pediatrician’s office for antiretroviral therapy follow for her 2 month old baby. The physician documents an expanded problem focused history and performs a brief exam. Upon review of the lab results, the physician makes the decision to modify the antiretroviral medication. A revised treatment plan is discussed and the physician advises the patient to return in 1 month.

Report an established patient office visit E&M CPT code based on level of history, exam and medical decision making

Office Report Dx Codes: E&M Inconclusive HIV Test Pre-exposure prophylaxis 99213

795.71 V01.79

34

Antiretroviral Therapy Visit Newborn

Case Study#8 Rationale • • • • • • •

An HIV+ mom visits the pediatrician’s office with her 2 month old baby for antiretroviral therapy follow up This is considered a sick visit encounter An expanded problem focused history and brief exam is performed and documented in the health record.

Lab results are reviewed which results in modification of the medication.

Prescriptions are dispensed and documented in the health record The E&M components are: expanded problem focused history, expanded problem focused exam and medical decision making is low Assign an established patient E&M code based on the level of care provided.

The E&M code for this scenario is 99213 (refer to slides 4-6)

35

Antiretroviral Therapy Visit Newborn

Case Study#8 Rationale (con’t) – refer to slide 13 • An HIV+ mom visits the pediatrician’s office with her 2 month old baby for antiretroviral therapy follow up • The HIV+ diagnosis that the newborn has, is the mother’s antibody status • “False positive” diagnosis could last up to 18 months in newborns • Report inconclusive HIV test results and pre-exposure prophylaxis - ICD9-9-CM codes 795.71 and V01.79

36

Why Is Documentation Important?

Complete Documentation ďƒŞ Correct Medical Coding ďƒŞ Appropriate Reimbursement

37

WEB RESOURCES • Centers for Medicare and Medicaid Services (CMS) – http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html http://www.cms.gov/center/coverage.asp

• Food and Drug Administration (FDA) – http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/IVDRegulatory Assistance/ucm124105.htm

• American Medical Association (AMA) – http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-yourpractice/coding-billing-insurance/cpt.page

National Center for Health Statistics (NCHS) http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html

• Centers for Disease Control (CDC) http://www.cdc.gov/mmrw/preview/mmwr.html

38

WEB RESOURCES • American Academy of Professional Coders (AAPC) http://www.aapc.com/resources/index.aspx

• American Health Information Management Association (AHIMA) http://www.ahima.org/resources/default.aspx

• The American Academy of Family Physicians (AAFP) www.aafp.org/online/en/home/practicemgt/codingresources.html

•

American Hospital Association (AHA) –

http://www.aha.org/advocacy-issues/medicare/ipps/coding.shtml

39

OTHER RESOURCES • CPT® 2012 Professional Edition. Publisher: American Medical Association.

• HCPCS Level II 2012. Publisher: Ingenix Optum.

• ICD-9-CM, Volumes 1 & 2, Professional. Publisher: Ingenix Optum.

• Faye Brown’s ICD-9-CM Coding Handbook 2012 (with Answers). Publisher: American Hospital Association.

• ICD-9-CM Fast Finder Sheets. Publisher: Ingenix Optum.

Note: Coding resources are updated annually. Please be sure to update coding resources each year.

40